The Other Side of the Tracks
Opiate maintenance treatment is a tale of two cultures. People who can afford Suboxone get to keep their addiction private. People who are restricted to methadone clinics pay the price of stigma.
Traditional approaches to addiction recovery have championed abstinence as the “right” path. Maintenance treatment for heroin or opiate painkillers has been used very cautiously—typically to rapidly taper addicts off opiods rather than for long-term use. As a result, when Hazelden announced last month that it will begin using medication-assisted treatment indefinitely for appropriate patients, many traditionalists responded with incredulity.
Opiod maintenance in the US primarily relies on two drug options: methadone, which has been around since the 1960s, and buprenorphine, which came on the market 10 years ago. Both drugs work by triggering opiate receptors in the brain, easing withdrawal and reducing the euphoric effects of heroin. Buprenorphine (brand name Suboxone) also includes naloxone, the anti-overdose drug that is added to prevent abuse.
Experts generally agree that methadone is more effective than Suboxone, but not by much. Studies have found that the recommended dose of Suboxone is better than low-dose methadone, but no better than high-dose. Yet methadone poses a greater risk of overdose and is easier to abuse. All things being equal, therefore, bupe is the preferred treatment. But all things are not equal, and most unequal is a patient's ability to pay.
The cost of bupe maintenance varies: many private insurance plans cover the drug, together with prescribing doctor’s visit; for people who pay out of pocket, the cost ranges roughly between $250 and $500 a month, not including doctor’s visit. Long a cheap generic, methadone is much less expensive. It is also more likely than Suboxone to be covered by public health insurance—though this varies by state—and some nonprofit and government-funded methadone clinics use a sliding scale to set patient co-pays.
“Suboxone is a white-collar alternative to methadone and NA," Tom says.
The cheaper generic version of Suboxone expected in 2013 may be postponed. Manufacturer Reckitt began hiking prices on Suboxone tablets earlier this year, likely in an effort to migrate Suboxone maintenance patients to the costlier sublingual film version for which they hold a patent through 2022. Now, Reckitt has announced its intention to withdraw the tablet form over the next six months, citing an increased risk of accidental pediatric exposure and poisoning. (Oddly, Reckitt did not move to immediately pull the tablets.) As a result, cheaper generic buprenorphine that would likely expand access is set to be delayed for "safety concerns."
Compare the situations of Tom and Jenna, who in many ways exemplify our nation's two classes of opiate maintenance patients.
Tom, who lives in Atlanta and is 25, began using opiods as a freshman in college. Throughout high school he had experimented with “alternative” drugs like psilocybin mushrooms and LSD, and steeping an opiod tea seemed like the next step in his drug evolution. But when eBay began prohibiting the sale of the dried poppies he had been purchasing, Tom went into withdrawal for the first time. He moved from snorting heroin to shooting it, eventually dropping out of college to become, as he put it, a “full-time junkie."
By the time Tom decided to get a handle on his habit and return to school, he had defaulted on his college loans. His school has a hardship clause; if he could demonstrate that chemical dependency was at the root of his default—and agree to maintenance therapy—he would could go back to college and be granted partial forgiveness on his loan interest. His private psychiatrist wrote him a prescription for a 30-day supply of Suboxone. He’s been on the drug for the past two years and is set to graduate this spring.
The vast majority of doctors who prescribe bupe have affluent caseloads. Those who serve poor and uninsured patients tend not to get the waiver, presumably on the assumption that their patients cannot afford the treatment, according to Duncan. “Bupe is still unusual in low-income medical settings due to economic inaccessibility, so providers there may not be as knowledgeable about it." Even those doctors who are aware of Suboxone tend not to waste time educating patients about unavailable treatments. This cycle reinforces itself.
The evolving view of addiction as a disease of the brain rather than as a moral failure has had important implications for both addicts and doctors. Only a decade ago, addiction was generally considered outside the scope of a non-addiction psychiatrist or a primary care physician; now buprenorphine is sparking more and more opiate addicts to get treatment independent of the traditional recovery routes, particularly methadone clinics. "We have the mainstreaming of addiction treatment into [general] medicine with Suboxone," Duncan says. "In primary care a patient tends to have a partnership with their doctor. No one has to know."
For people who depend on traditional recovery at methadone clinics it is a very different matter—they face the traditional stigma that attaches to addiction. The best example? The speed and frequency with which "Not in My Backyard" protests spring up at the very mention that a methadone clinic might be located in the neighborhood. This stigma may be taken for granted, and the problems it causes are predictable.
Irish researchers studying methadone treatment at OTPs this year found that "linkages between social control and institutional stigma that serve to reinforce 'addict' identities, expose undeserving customers to the public gaze, and encourage clients to be passive recipients of treatment." A federally funded study of methadone policy found that "frequent clinic visits hinder patients' full reintegration into society by restricting their ability to travel and imposing continued contact with less stable patients. Such restrictions may also deter out-of-treatment patients, who see an unending, inconvenient and stigmatized regimen." In this way, the necessity of daily visits to a methadone clinic can prevent people who are in recovery from recovering their place as functional and respected members of society: once an addict, always an addict. As a result, some opt out of methadone treatment; others opt out of society to go on treatment.
People who depend on traditional recovery at methadone clinics face traditional addiction stigma.
Another important difference between methadone and buprenorphine is their dosing requirements. People on methadone must make frequent visits to the clinic—usually daily for the first 30 to 90 days—to receive their doses in order to prevent “diversion,” the act of misusing or selling the drug. Those prescribed Suboxone, however, may get anywhere from a week’s to a month’s supply. In most states, methadone maintenance patients are allowed a month’s worth only after showing two years of compliance—clean drug tests and, often, mandatory counseling or meetings. (In Florida, it is five years.) When traveling, methadone-takers must put in a vacation request at their clinic to qualify for extra medication, or “take homes”; if they do not qualify, they have to set up courtesy dosing at a clinic near their destination. Bupe-takers merely pack the right number of pills.
The emerging approach to treatment—non-specialist physician prescriptions for opiod dependence—has its own drawbacks. Many people in recovery benefit from a combination of medication and self-help or counseling in order to address the many issues related to addition. But in a recent SAMHSA study, 41% of bupe patients had attended no substance abuse or mental health counseling sessions in their first month of treatment. On this score, methadone clinics that require such attendance may have an advantage.
The disease model of addiction is widely perceived as resulting in a decrease in stigma. (It could be argued that popular culture's obsession with celebrity—and their high rates of substance abuse—has done more.) Yet the stigma persists, especially for people who live on the margins because of the color of their skin or the size of their income—those who stand in line at the nation's methadone clinics. While no less an "addict," a person who is on Suboxone can, if desired, entirely skirt the stigma by keeping their disease private, even a secret, including no public acknowledgement at a clinic or a 12-step meeting. As Tom points out, bupe is white-collar maintenance; methadone is for everybody else.
There’s nothing new in how society confers social stigma on those who live on have nots. If we truly believe addiction is a medical disease, then it seems cruel to restrict the economically disadvantaged to the treatment that is more burdensome in terms of risk, adherence and disrespect. Making Suboxone available at methadone clinics will not magically make stigma disappear, but it is likely to improve the odds of a successful recovery for people who have nowhere else to go.
Kelly Bourdet is a journalist focusing on the culture of science, technology and medicine. Her work has appeared in Vice, Motherboard, Buzzfeed's FWD, Nerve, Black Book and other publications. She tweets at www.twitter.com/kellybourdet.